Registration Information
Email Address*:
First Name*:
Last Name*:
Address*:
City, State, Zip*:
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Home Phone:
()
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Cell Phone:
()
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Work Phone:
()
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ext
Birthday:
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Comments:
Breast Cancer Survivor?
Yes
No (optional)
If yes, for how many years?
I wish to volunteer for the Madison Affiliate of Susan G. Komen for the Cure. I understand that the nature of volunteer activities that I may perform in my capacity as a volunteer may involve physical activity, contact with unidentified and or unfamiliar persons, or other potential risk of bodily injury or damage to property. Knowing this and in consideration of being allowed to volunteer, I HEREBY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY PERSONAL INJURY AND OR PROPERTY DAMAGE THAT I SUSTAIN OR CAUSE DURING MY PARTICIPATION AS A VOLUNTEER. IN ADDITION, I HEREBY RELEASE, HOLD HARMLESS AND COVENANT NOT TO FILE SUIT AGAINST THE KOMEN MADISON AFFILIATE, THE SUSAN G. KOMEN FOR THE CURE AND ANY OF THEIR EMPLOYEES, VOLUNTEERS, PARTNERS, AGENTS, SPONSORS, BOARD MEMBERS AND SUCCESSORS FROM ANY AND ALL LOSS, LIABILITY OR CLAIMS I MAY HAVE ARISING OUT OF MY SERVICE AS A VOLUNTEER. I give my full permission to the Komen Foundation and its local Affiliates and Races and their sponsors and corporate sponsors to use any photographs, videotapes, audiotapes or other recordings of me that are made during the course of this event.
I am over 18 years of age and have read the above disclaimer*.
* = Required field.
